Four patients with pseudocyst of the spleen gave histories of abdominal trauma. In one patient the pseudocyst had ruptured, necessitating emergency splenectomy 34 years after the original injury. In a second patient the pseudocyst was discovered incidentally, and was managed by spleen-preserving excision; and the third and fourth presented with abdominal pain and had splenectomy and spleen-preserving surgery, respectively. All patients with conservatively treated splenic injury are at risk of developing a pseudocyst of the spleen, and the lesion can be detected by computed tomography or ultrasound. When there are no symptoms the natural history is unknown; but if surgery is necessary, splenectomy can sometimes be avoided.
Although adult hypertrophic pyloric stenosis (AHPS) is an uncommon condition, there are nine reports of true pyloric muscle hypertrophy with, in addition, infiltration of gastric carcinoma cells between the muscle fibres' -5 . The surgeon should be aware of this association when operating on a patient with AHPS as a full-thickness biopsy is essential for identification of simple AHPS and certain exclusion of carcinoma. The patients presented here lead us to recommend partial gastrectomy as the treatment of choice in all cases of hypertrophic pyloric stenosis in adults. Case reports Case 1A 47-year-old hypertensive man developed copious vomiting of bile-free food in 1975. Adult hypertrophic pyloric stenosis (AHPS) was diagnosed after two barium meals and three gastroscopies without biopsy. He underwent truncal vagotomy and Weinberg pyloroplasty without biopsy. Nine months postoperatively he developed recurrent dyspepsia. Gastroscopy showed a friable prepyloric lesser curve with gastritis and intestinal metaplasia (but no malignancy) on biopsy. The pylorus was wide open. His symptoms were temporarily controlled with metoclopramide but recurred in 1978 when gastroscopy showed a pale, smooth antral lesser curve without ulceration. No biopsy was taken. The pylorus was open. In 1982 he developed belching and halitosis. Barium meal showed recurrent pyloric stenosis. At laparotomy the pyloric muscle was thickened with narrowing of the canal. A 50 per cent Polya gastrectomy was carried out (Figure 1). Examination of the specimen showed that the wall of the pyloric canal was thickened (26 mm) by muscle hypertrophy. In addition there were slender cords of signet-ring adenocarcinoma cells running through the hypertrophied muscle and an ulcerating poorly differentiated carcinoma on the prepyloric lesser curve with serosal extension and lymph node involvement. Five months later he died with disseminated intra-abdominal carcinoma. Case 2A 57-year-old man with ischaemic heart disease developed dyspepsia, weight loss and vomiting over nine months. Barium meal and gastroscopy showed pyloric stenosis. Biopsy of the prepyloric area showed undifferentiated signet-ring adenocarcinoma. He underwent Polya gastrectomy. The wall of the pyloric canal was 23 mm thick with marked muscle hypertrophy and diffusely infiltrating signet-ring malignant cells, very similar to case 1. DiscussionAdult hypertrophic pyloric stenosis (AHPS) is a curious condition. Although responsible for up to 2 per cent of cases of pyloric obstruction in adults6 only about 300 cases are reported in the literature7. This discrepancy may be partly due to a lack of awareness of the adult type of pyloric muscle hypertrophy in contrast to the well recognized congenital form. Most patients are between 30 and 60 years old at presentation and male predominance is not as marked as in the congenital type'. The classification of AHPS suggested by Berk' stresses that some cases are primary or idiopathic but the majority are associated with some local ulcerative or inflammatory co...
Ampicillin was compared with a penicillin and sulphadiazine combination as a topical wound application in patients undergoing biliary or gastrointestinal surgery in a controlled study. Eleven of the 53 patients having a topical application of penicillin and sulphadiazine developed wound sepsis (20·8 per cent) compared with 4 of the 59 patients receiving ampicillin (6·8 per cent). This difference is significant (P≤0·01).
CorrespondenceWe do not claim that our method oftreatment is curative and thus the argument concerning histological proof assumes less importance. The majority of patients have shown unequivocal evidence oftumour progression, but it is ofinterest that our 2 longest survivors at 36 and 58 months had positive histological proof of their disease. Furthermore, it would be noted that 6 our of the 15 patients who survived curative resections in the series reported by Blumgart el a/.' subsequently died from the effects of recurrent tumour.Only a randomized trial will resolve the issue and determine the place, ifany, of radical surgical excision in this difficult condition.
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